APPLICATION FORM
PROFESSIONAL CERTIFICATE
IN YOUTH PSYCHIATRY

Personal Details

First Name

Surname

Address

If International - other, please enter location here.

Preferred Contact Number

Preferred Email Address

Professional Details

Workplace

Qualifications

Role

Psychiatry Trainee

Psychiatry Consultant

Other

If Role - other, please enter your role here.

AHPRA Registration Number

(or equivalent international registration agency):

Other Qualifications: Please upload here.

If you do not have an AHPRA registration number, please provide evidence of your qualification as a psychiatrist or GP (e.g., registration with your national professional association or academic transcript).

Drop your files here

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APPLICATION FORMPROFESSIONAL CERTIFICATEIN YOUTH PSYCHIATRY